Take me to the forest: Changing hospital culture

We recently had a staff meeting where a guest speaker prepared a presentation about communication. At one point in the presentation, the speaker encouraged the audience to play the telephone game, in an attempt to illustrate how messages are distorted while they are passed from one person to another. This innocent game, where one person whispers the message to the next person and then through a line of people until the last person loudly announces the message to everyone, took an odd turn. And rather than making me think about communication, it brought back a difficult question on hospital culture: How can we change the insidious culture of “name, shame and blame” that still exists? Why can we not see the forest, and focus solely on the trees?

The first sentence of the game was “Patient in room 5 is bleeding and needs a transfusion”. By the end of the game, after this sentence has been passed through about 40 people, the sentence became “Patient has a uterine cyst and Linda will be back next week”. Obviously, the point was made: messages are altered and errors accumulate in the retelling. However, once the presenter concluded the game, one person stood up and said: “It would be great to find out where exactly the message was changed! Let’s go through each person and find out WHO was the first to change the message!” To which the presenter (!) and others joined in. And here we are, trying to find a person to blame for altering the message, missing the whole point of this exercise and sinking deeper into our conditioned thinking pattern: asking “Who did this” instead of “Why does this happen”.

The mantra “name you, shame you and blame you” has a long tradition in healthcare. It is morally hurtful to the workers, and as many studies on error reporting show, it is a huge barrier in achieving patient safety.  The reason why this tradition continues, even when efforts to build a just culture are being made, is well formulated by John Toussaint. He recalls ThedaCare’s early transition to a lean organization and the challenges of changing this culture:

“Shame and blame is one of the largest hurdles to overcome in the journey toward lean healthcare […]. As disciplinary models go, shame and blame has a distinct advantage: it’s fast and easy. A cursory glance at a situation is all the evidence that is needed to decide on a culprit. And feeding the rumor mill with the guilty party’s name is infinitely easier than launching an investigation […]. But shame and blame has a terrible price. In that environment, there is no motivation to report errors and safety issues. If staff is blind to error and its cause, there is little hope for improvement.” 

Incidentally, the person with the suggestion is a nurse instructor, and the presenter is a senior nurse working as an improvement facilitator. Far from blaming these people who perhaps had the best intentions and just missed the underlying significance of the prodding, I am standing here blaming myself: what can I do to change this? Should I have said something, and if so, what exactly? Would that have been a good idea, or would that just throw me off the boat I am trying to shake? I felt defeated at the time and secluded in my own beliefs that change is possible (I picked up myself rather quickly though).

Culture change is difficult, but not impossible. I believe we are missing role models at work; leaders who can inspire and can make us feel that challenging the status quo is accepted and celebrated, as a commitment to our profession and to our patients. Leaders who would say that even though the last message of the telephone game was nothing like the original message, we openly accept this without blame. That this is an occasion to celebrate our differences, and acknowledge our human, erring nature but also our innate human desire to always improve and accept challenge. And, that even if some trees in the forest are green and some are broken, they all make up an exquisite picture: the forest itself is just glorious. 

(n.b. name has been changed for privacy)